Provider Demographics
NPI:1649286287
Name:PESKIN ORAL SURGERY, LTD.
Entity type:Organization
Organization Name:PESKIN ORAL SURGERY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER-ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:PESKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-676-4590
Mailing Address - Street 1:4711 GOLF RD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1224
Mailing Address - Country:US
Mailing Address - Phone:847-676-4590
Mailing Address - Fax:847-676-4695
Practice Address - Street 1:4711 GOLF RD
Practice Address - Street 2:SUITE 408
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:847-676-4590
Practice Address - Fax:847-676-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL705470Medicare ID - Type Unspecified